BAPTIS KEDIRI STIKES

STRATA NURSING PRODUCT 1

BASIC NURSING FORM

STUDENT NAME : ……………………………………………………

NIM : ……………………………………………………
SPACE : ……………………………………………………
DATE : ……………………………………………………

1. BIODATA:
Patient's Name : ………………………………………………. ............ .......
Nickname : ………………………………………………. ...........................
Age : ………………………………………………. ............
Status : ………………………………………………. ............
Religion : ……………………………………………….
Education : ………………………………………………. ............
Occupation : ………………………………………………. ............
Earnings : ………………………………………………. ............
Address : ………………………………………………. ............
Medical Diagnosis : ……………………………………………….
MRS Date : ……………………………………………….
Date of Assessment : ……………………………………………….
Blood Type : ………………………………………………. .

2. MAIN COMPLAINTS

3. HISTORY OF DISEASE NOW

4. PAST DISEASE HISTORY

5. FAMILY HEALTH HISTORY

GENOGRAM :

6. VITAL SIGNS
Temperature : ................................. º C
Pulse : …………………………… x / minute
Blood Pressure: …………………………… mmHg
Respiration : …………………………… x / minute
TT / TB : …………………………… Kg, …………… .cm
7. DAILY ACTIVITY PATTERNS

a. Personal Hygiene Needs

b. Nutrition Needs / Nutrition Patterns

c. Needs for Elimination / Elimination Pattern of BAK, BAB

d. Oxygenation Needs

e. Fluid and Electrolyte Needs

f. activity needs
g. The Need for Safety and Comfort

h. Psychosocial and Spiritual needs

8. STATE / APPEARANCE / PUBLIC IMPRESSION

9. PHYSICAL EXAMINATION
A. Head and Neck Examination

B. Pemeriksaan Integumen Kulit dan Kuku :

C. Breast and Underarm Examination (If needed):

D. Chest / Thorak examination
Thorax Inspection:

Lung:

E. Heart Check:

F. Abdomen Examination:

G. Sex Check and surrounding area (if needed):

Geneticist:

Anus :
H. Musculoskeletal examination:

I. Neurology Examination:

J. Mental Status Check:

10. Pemeriksaan Penunjang Medis :

11. Implementation / Therapy:

12. Client / Family Expectations regarding his illness:

Kediri, ............................
College student,
 DATA ANALYSIS

PATIENT'S NAME :
AGE :
NO. REGISTER :

SOFT DATA RELATED FACTORS / NURSING (NANDA)

OBJECTIVE DATA RISK (E) PROBLEMS
SUBJECTIVE DATA
 NURSING PLANNING

PATIENT'S NAME :
AGE :
NO.REGISTER :

NURSING DIAGNOSIS :
 NOC: ................................................ .................................................. .
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................

NOC: ................................................ ..................................................

…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................

NOC: ................................................ ................................

…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
Note: (retained / enhanced) strikethrough one
LIST OF NURSING DIAGNOSIS

PATIENT'S NAME :
AGE :
NO. REGISTER :

NO DATE NURSING DIAGNOSES DATE SIGNATURE

APPEAR TERATASI
\ Askep format 201 7
 NURSING PLANNING

PATIENT'S NAME :
NO.REGISTER :
NO NURSING DIAGNOSES INTERVENTION RATIONAL TTD
(NIC)

\ Askep format 201 7

 NURSING ACTIONS

PATIENT'S NAME :
AGE :
NO.REGISTER :

NO NO.DX TGL/JAM NURSING ACTIONS SIGN

HAND
\ Askep format 201 7

NOTES OF DEVELOPMENT

PATIENT'S NAME:
AGE :
DATE :
NO NO.DX HOUR EVALUATION (SOAP)
\ Askep format 201 7